Fillable Form W-2as - American Samoa Wage And Tax Statement

Notice to Employee

your employer. Enter this amount on the wages line of your tax return. (Form

1040-SS filers, see the instructions for Form 1040-SS, Part I, line 5.) By filing this

Do you have to file? Refer to the Form 1040 instructions to determine if you are

form, your social security tips will be credited to your social security record (used

required to file a tax return. Even if you do not have to file a tax return, you may be

to figure your benefits).

eligible for a refund if box 2 shows an amount or if you are eligible for any credit.

(Also see the Instructions for Employee on this page and the back of Copy C.)

Copies B and C; corrections. File Copy B of this form with your 2016 American

Instructions for Employee

Samoa income tax return. Keep Copy C for your records. If your name, social

security number (SSN), or address is incorrect, correct Copies B and C and ask

your employer to correct your employment record. Be sure to ask your employer

(Also see Notice to Employee on this page.)

to file Form W-2c, Corrected Wage and Tax Statement, with the Social Security

Box 5. You may be required to report this amount on Form 8959, Additional

Administration (SSA) to correct any name, amount, or SSN error reported to the

Medicare Tax. See the Form 1040 instructions to determine if you are required to

SSA. Be sure to get your copies of Form W-2c from your employer for all

complete Form 8959.

corrections made so you may file them with your tax return.

Box 6. This amount includes the 1.45% Medicare Tax withheld on all Medicare

Estimated tax. If you expect to owe $1,000 or more in tax (including self-

wages and tips shown in box 5, as well as the 0.9% Additional Medicare Tax on

employment tax) for 2017, you may have to make estimated tax payments to the

any of those Medicare wages and tips above $200,000.

U.S. Internal Revenue Service. Use Form 1040-ES, Estimated Tax for Individuals.

Box 11. This amount is (a) reported in box 1 if it is a distribution made to you from

Clergy and religious workers. If you are not subject to social security and

a nonqualified deferred compensation or nongovernmental section 457(b) plan or

Medicare taxes, see Pub. 517, Social Security and Other Information for Members

(b) included in box 3 and/or 5 if it is a prior year deferral under a nonqualified or

of the Clergy and Religious Workers.

section 457(b) plan that became taxable for social security and Medicare taxes this

Cost of employer-sponsored health coverage (if such cost is provided by the

year because there is no longer a substantial risk of forfeiture of your right to the

employer). The reporting in box 12, using code DD, of the cost of employer-

deferred amount. This box should not be used if you had a deferral and a

sponsored health coverage is for your information only. The amount reported

distribution in the same calendar year. If you made a deferral and received a

with code DD is not taxable.

distribution in the same calendar year, and you are or will be age 62 by the end of

the calendar year, your employer should file Form SSA-131, Employer Report of

Credit for excess social security tax. If you had more than one employer in 2016

Special Wage Payments, with the Social Security Administration and give you a

and more than $7,347 in social security tax was withheld, you can have the excess

copy.

refunded by filing Form 843, Claim for Refund and Request for Abatement, with

the Department of the Treasury, Internal Revenue Service Center, Austin, TX

Box 12. The following list explains the codes shown in box 12. You may need this

73301-0215, USA. However, if you are required to file Form 1040 with the United

information to complete your tax return. Elective deferrals (codes D, E, F, and S)

States, you must claim the excess tax as a credit on Form 1040.

and designated Roth contributions (codes AA, BB, and EE) under all plans are

generally limited to a total of $18,000 ($12,500 if you have only SIMPLE plans;

Unreported tip income. You must file Form 4137, Social Security and Medicare

$21,000 for section 403(b) plans if you qualify for the 15-year rule explained in

Tax on Unreported Tip Income, with your income tax return to report at least the

Pub. 571). Deferrals under code G are limited to $18,000. Deferrals under code H

allocated tip amount unless you can prove a smaller amount with adequate

are limited to $7,000.

records. If you have records that show the actual amount of tips you received,

report that amount even if it is more or less than the allocated tips. Use Form 4137

However, if you were at least age 50 in 2016, your employer may have allowed

to figure the social security and Medicare tax owed on tips you did not report to

an additional deferral of up to $6,000 ($3,000 for section 401(k)(11) and 408(p)

SIMPLE plans). This additional deferral amount is not subject to the overall limit on

elective deferrals. For code G, the limit on elective deferrals may be higher for the

last 3 years before you reach retirement age. Contact your plan administrator for

more information. Amounts in excess of the overall elective deferral limit must be

included in income. See the “Wages, Salaries, Tips, etc.” line instructions for your

tax return.

(continued on back of Copy C)

Form W-2as - American Samoa Wage And Tax Statement - 2016 Page 5

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